Bilateral Descemet Membrane Detachment Following Cataract Surgery

Descemet membrane detachment (DMD) is a sight-threatening complication that has been reported after diverse surgical procedures. Unilateral DMD typically arises as the result of engagement of the Descemet membrane during intraocular surgery.^1-3 We report an unusual case of bilateral DMD occurring spontaneously several weeks after sequential uncomplicated phacoemulsification cataract extraction. We review previously reported cases and propose that these eyes share an underlying weakness of Descemet membrane attachment.

A 64-year-old man underwent uncomplicated right phacoemulsification cataract extraction with a temporal clear corneal incision. Although initially excellent, his vision deteriorated 10 days postoperatively. At 2 weeks, visual acuity was 20/120 with superior corneal edema remote from the temporal incision. At 1 month, visual acuity had reduced to count fingers with widespread corneal edema and total DMD (Figure, A and B).

The patient was referred to the Cornea Service and was seen 8 weeks postoperatively. The total DMD persisted despite medical therapy and the patient underwent an intracameral air injection with postoperative supine posturing. This allowed complete reattachment of the Descemet membrane and visual acuity improved to 20/30 unaided with a clear cornea albeit with a peripheral Descemet fold (Figure, C and D).

After giving informed consent, the patient underwent phacoemulsification cataract extraction in his left eye. Preoperatively, the left cornea was clear (Figure, E). Surgery was uncomplicated. As a precaution, an injection of intracameral air was given at the end of surgery and the patient was postured supine for 6 hours postoperatively. On the first day postoperatively, the cornea was clear with an adherent endothelium. However, at 2 weeks, there was edema of the superior third of the cornea with a partial DMD distant from the temporal corneal incision. Visual acuity was reduced to 20/120. The next day, he underwent an injection of air into the anterior chamber with supine posturing. Postoperatively, his endothelium reattached with an unaided visual acuity of 20/30 (Figure, F). Postoperative specular microscopy revealed healthy endothelial cells, with cell counts of 2018/mm² and 2275/mm² in the right and left eyes, respectively.

Unilateral DMD typically occurs at the time of surgery and is thought to be related to poor wound construction and direct Descemet membrane trauma.^1-3 Bilateral, post–cataract extraction DMD, however, is rare and typically occurs in uncomplicated procedures. It has been reported previously in 12 patients.^4-13 In this report, we summarize the clinical characteristics of these cases, together with our own (Table). Median patient age was 77 years with no sex bias. The condition occurs mostly in association with phacoemulsification techniques (21 of 24 eyes where information available [81%]) and clear corneal incisions (14 of 19 eyes [74%]). Descemet membrane detachment was identified either intraoperatively or on the first postoperative day in 10 of 21 eyes (48%), with another 8 (38%) only becoming apparent after 2 weeks. Endothelial guttata were identified in 3 of 13 patients (23%).

Six of the 26 affected eyes (23%) resolved with medical (nonsurgical) therapy alone. The remaining 20 (77%) all underwent pneumatic descemetopexy, which permanently reattached the Descemet membrane in 17 cases (85%). Sulfur hexafluoride was the most commonly used gas. Three eyes (11.5%) required penetrating keratoplasty. Visual outcome was generally good, with a median best-corrected visual acuity of 20/30 (range, 20/20-20/100).

The etiology of bilateral, post–cataract extraction DMD is poorly understood. Although endothelial guttata have been documented in some eyes, most corneae have a normal appearance on slitlamp and specular microscopic examination.

The occurrence of bilateral, post–cataract extraction DMD is rare but its incidence is increasing. The Table shows that only 2 cases were reported before 1990, whereas 6 cases have been described in the last decade alone. This may relate to increasing use of clear corneal incisions in phacoemulsification cataract surgery. We propose there is inherent weakness of adhesion between the Descemet membrane and the underlying stroma in these patients and suggest further investigation be directed at collagen fibrillary attachment and anchoring protein function in affected individuals. Although confocal microscopy and high-resolution anterior segment optical coherence tomography may prove helpful, the ultimate pathology may only be determined through histological examination.

Correspondence: Dr O'Brart, Department of Ophthalmology, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, England (davidobrart@aol.com).

Previous Presentation: This work was presented at the Trends in Ophthalmology Meeting; February 3, 2012; London, England.